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TRANSIT
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TALKING POINTS1. The ingredients of Transitions in Care (TIC)
a. The opportunity for home healthb. Does your hospitalization & readmit rate get you a seat at the table?c. Does the hospital/health system have significant exposure to the
TIC penaltiesd. Does the hospital/health system have significant costs associated
with Emergency Department and Vacated Days for re-hospitalized patients within 30 days of their discharge?
e. Is data available to analyze?I. Patient rehospitalizationsII. Post acute referrals, if any III. Number of vacated days and ED incidents leading to readmissionsIV. Average cost per bed day and ED incidentV. Outcomes and HHCAHPS
TALKING POINTS
2. Identify the services to be included to meet the goals of reduced ED incidents and re-hospitalizations of the non-post acute referred patients
a. Development of patient identification criteria protocols to be implemented by the hospital/health system
b. Development of the service components for a 35 day programa. Skilled nursing assessmentb. Social service component to identify and engage community
support agenciesc. Telehealth for patients with at-risk diagnosed. Medical Record Requirements
3. Identify the Direct Costs related to the desired services and developing
price points (Gross Profit Margins) for selling these services
TRANSITIONS IN CARE – THE ISSUES
The ACA provisions for Transitions in Care take effect in 2013
Provides for penalties to hospitals whose re-hospitalization rates exceed levels as determined by CMSoRe-admissions are above national average for AMI,
Heart Failure and Pneumonia beginning with discharges on or after Oct. 1, 2012.
oThe penalties are 1%, 2%, and 3% of Medicare payments graduated from 2013 to 2015
oThe penalties are separate from the lost revenue from vacated days due to re-hospitalizations within 30 days of discharge
oMany hospitals have an exposureoCMS has stated that “64% of re-hospitalizations are
patients discharged without a post acute referral”
TRANSITIONS IN CARE – THE HOSPITALS’ ISSUES
Inadequate discharge planning for significant numbers of patients Budget constraints – appropriate staffingo Inability to identify all “at risk” patients, regardless of
“homebound statuso Appropriate clinical and social service staffing componentso Protocols
Late day discharges by physicians without notification Lack of a post acute service component to prevent re-
hospitalizations with 30 days of dischargeo Can not provide free care to a patient using hospital
employees Violation of the “Stark” laws
TRANSITIONS IN CARE – HOME CARE’S OPPORTUNITIES
A non-hospital-based agency can provide services to non-homebound
patients paid for by the hospital Who gets a seat at the table?
• Excellent Home Health Compare and HH-CAHPS scores• Avoidance of Adverse Events (drivers of hospitalization)• Low re-hospitalization and ED incidents• Patient transition protocols• Service plan design, including technology with the right
pricing
Getting a Seat at the TableDoes your agency stand out?
DO YOU DESERVE A SEAT AT THE TABLE?• Excellent Outcomes and Low Hospital and Emergent
Care Usage Compare scores
Source: SHP National Database. Provider: VNA of Cape Cod
DEMONSTRATING SOUND BUSINESS PRACTICES
Source: SHP National Database. Provider: VNA of Cape Cod
DO YOU DESERVE A SEAT AT THE TABLE?
• Demonstrating beneficiary satisfaction (excellent HHCAHPS results
Source: SHP National Database. Provider: VNA of Cape Cod
BRINGING TRANSPARENCY TO THE TABLE
• Hospitals want to see detailed data• Although it’s helpful to show risk-adjusted scores,
they’re oftentimes more interested in raw numbers• Hospitals find benchmarks interesting, and local
benchmarks even more interesting
DO YOU DESERVE A SEAT AT THE TABLE?
Source: SHP National Database.
WHEN DO MOST OF YOUR READMISSIONS OCCUR?
WHY RAW COUNTS ARE IMPORTANT
DEMONSTRATING TRENDS
ARE YOU GETTING ADMISSIONS THAT ARE HIGHLY LIKELY TO RE-HOSPITALIZE?
HOME HEALTH NEEDS TO IMPROVE INTERVENTIONS TO KEEP HIGH RISK PATIENTS FROM READMITTING
Communities that have a high hospital utilization rate also have higher readmit rates.
THE TRANSITIONS IN CARE SERVICE PROGRAM
THE “TRANSITIONS IN CARE”SERVICE PROGRAM
• The patient belongs to the agency as a separate service from Medicare patients.
• Tele-health monitoring program must be separated other patients
• Nursing assessment visit includes:• Completion of necessary intake and clinical assessment
information to manage (and monitor) the patient • Identify social service needs and safety issues requiring
an OT• Performance of a thorough Medication reconciliation• Schedule a physician follow-up appointment if not already
scheduled• Verification of current medication orders• Verification of vital sign parameters and when to notify
physician if monitoring is ordered.
THE “TRANSITIONS IN CARE”SERVICE PROGRAM
• Ongoing remote monitoring of vital sign via tele-health, as ordered
• Must have a process for monitor removal• Performance of necessary telephone contact with patient
and attending physician• Vital sign alerts• Other signs or symptoms indicating a potential problem
• Follow-up visit(s) not anticipated unless ordered by attending physician
• Program must be included in agency’s quality and performance
improvement process
THE “TRANSITIONS IN CARE”SERVICE PROGRAM
• Must have a written agreement with hospital outlining exactly what the agency will do and the agreed upon payment rates:• Purpose of program• Physician participation and orders required• Non-OASIS assessment RN visit• Ongoing monitoring via tele-health, as necessary
• Agreement must specify that the program is for a minimum
patient service period of 35 days from hospital discharge at no charge to the patient
THE “TRANSITIONS IN CARE”SERVICE PROGRAM
• Must identify patient enrollment exclusions:• Strong history of non-compliance with meds, diet and
physician appointments• Evidence of unsafe home environment – patient not safe at
home• Must be attending physician who also agrees to manage
the patient care with goals:• To maintain and improve patients health• To prevent unnecessary re-hospitalizations and emergency
room visits• To provide patient education ands support/mentoring
regarding symptom and medication management• To promote compliance with appropriate disease
management principles• Teach self care and independence to patients and
families/caregivers
PRICE POINT DEVELOPMENT
PRICE POINT DEVELOPMENT
Visit Pricing to be developed:
1. Nursing visits- initial and follow up
2. Physical Therapy
3. Occupational Therapy
4. Social Work
PRICE POINT DEVELOPMENT
Consideration---
Should you price at full cost including allocated overhead or do you default to managed care visit prices?
Do your managed care prices per visit constitute a floor for pricing of this model?
Should you use the visit costs that your Medicare cost report show on Worksheet C Part I? Is a specific cost finding more appropriate?
PRICE POINT DEVELOPMENT
Calculation of cost of an initial and follow up nursing visit:
Direct cost per RN visit averages $77.76 per visit overall.
Total visits were 9,249. Total direct costs were $719,202.
Here is how to isolate the cost per type of RN visit:
RN visits Time Visit Weight % Direct cost Per Visit
Admissions 1,214 1.60 1942.40 18.9% $135,881 $112
Discharges 1,214 1.25 1517.50 14.8 106,157 87
Follow up 6,821 1.00 6821.00 66.3 477,164 70
Using 120% of direct cost to in order to account for overhead, your visit price would be $135 Initial Visit , $84 Follow Up Visit and $21 for a Telephone Follow-up.
PRICE POINT DEVELOPMENT
What cost do you use for pricing an RN visit?
Medicare cost report: $138
Specific cost finding: Initial $ 135 Follow up $84 Telephone Follow-up $21
Largest managed care contract rate: $119
Is this your lowest price?
PRICE POINT DEVELOPMENT
Calculation of PT/OT Visit costs:
Using fully allocated costs per cost report, since all visits are equal:
PT $132
OT $133
Use $135 per visit.
Note: costs include employees and contracted staff combined and are derived from Worksheet C Part I of the cost report modified to reflect managed care division costs.
PRICE POINT DEVELOPMENT
• Calculation of Cost for a Social Work Visit:
• Social work costs from the cost report are greatly distorted due to fewer actual visit being made--- much of the cost reflects telephone time.
• Need to do a cost finding on actual cost per visit:
• We looked at our hospice data due to larger staff and more in-person visits.
• We estimated that 60% of total direct costs relate to in-person visits.
• Total direct costs were $493,781. Visits were 3,096.
• As a result, direct costs were $97 per visit. Indirect costs were $58 per visit.
• Overall cost per visit is $155.
PRICE POINT DEVELOPMENT
Estimate for Telemonitoring costs:
All monitoring equipment is fully depreciated at this point.
Costs involve person assigned to pick up and deliver devices to the home and to on call charges for weekend monitoring of results
Based upon total monthly costs divided by average number of monitors in use, we have a monthly charge of $70.
Applying 120% of direct cost formula to account for overhead, we arrive at a monthly charge of $84.
PRICE POINT DEVELOPMENT
Recap of per visit costs:
Nursing—Initial $135
Nursing ---Follow up 84
PT 135
OT 135
MSW 155
Telemonitoring- per month 84
PRICE POINT DEVELOPMENT
Real life example of implementation:
Large Medicare Advantage plan contract provides for a bonus to reduce readmissions:
Base line readmission rate of 22%
Bonus based upon savings in hospital costs at $8,000 per admission times the difference between actual readmissions and the base line readmissions (22% of hospital discharges assigned to us).
Bonus equals cost of hospital readmissions avoided times:
15% if readmission rate drops by 11 to 20%
25% if readmission rate drops by 21 to 30%
30% if readmission rate drops by over 30%
COST / BENEFIT TO THE HOSPITAL
COST / BENEFIT TO THE HOSPITAL
• Large 500 bed teaching hospital in the Philadelphia metropolitan area
Total of 4,627 Medicare Fee for Service discharges in fiscal year 2011
1,074 (23.21%) discharged patients referred to Homecare 1,079 (23.32%) discharged patients referred to other post acute
settings 162 (3.50%) discharged patients expired 2,312 (49.97%) discharged patients not referred to any post
acute settings ! Hospital does not track its re-admission data! Hospital’s variable cost per Bed Day is $1,130 and likely a
$1,950 total cost Hospital’s variable cost of an Emergency Room visit is
$124.30 and likely a $ 214.31 total cost Hospital’s re-admission rate on Hospital Compare is above
the national average for all reported measured diagnoses! Hospital’s H-CAHP scores are all below national averages!
COST / BENEFIT TO THE HOSPITAL
• The Hospital’s 2011 Medicare revenue was $101,000,000.
• If this was 2013, the Hospital’s 1% penalty risk is $1,010,000
• The Vacated Days and ER visits are estimated:• Assuming an average of 3 re-hospitalized days for each
patient and a 50% patient usage of an emergency room visit (actual data unknown)
• Estimated variable cost:2,312 patients discharged x 23.07% readmission rate =
533 patientsx 3 re-hospitalized days = 1599 days @ $1,130 =
$1,806,87050% of 533 patient admitted through ER @ 124.30 =
33,126
$1,839,996
COST / BENEFIT TO THE HOSPITALVARIATION AND COSTS OF SERVICES FOR 35 DAYS:
PatientVariation
RNAssessme
nt
RNFollow-up
Calls
Social Service
Visit
OT VISIT
Tele-healthMonitoring
Total Cost Per
patient
RN Only $ 135 (4) $84
$ 219
Monitoring
$ 135 (4) $84
(35) $98 $ 317
OT $ 135 (4) $84
$ 133 (35) $98 $ 450
Soc. Work
$ 135 (4) $84
$ 155 $ 133 (35) $98 $ 605
COST / BENEFIT TO THE HOSPITAL
• Assumed cost of Vacated Days and ER Visit Costs $ 1,839,996
• Cost of Services – 2,312 patients• 30% RN only 694 @ $219 = $ 151,986
• 25% RN & Monitoring 578 @ $317 = 183,226
• 20% RN, Monitoring and OT 462 @ $450 = 207,900
• 25% RN, Monitoring OT & SS 578 @ $605 = 349,690 892,802
• Net Savings to Hospital $ 947,194
HOSPITAL READMISSION STUDY WITHIN THE 30-DAY DRG PERIOD
HOSPITAL READMISSION STUDYWITHIN THE 30-DAY DRG PERIODLarge Regional Medical Center in a Western State
680 Readmits (single and multiple)of Medicare Patients within the DRG Period resulted in 8,214 inpatient days for FY 2003
23.53% re-admission rate (2,890 Medicare discharges)!
12.08 average days per readmitted patient! Loss of $15,072,700 @ $ 1,835 per Bed Day Cost
Not including ER or any other Department Costs Only 80 of the Readmitted Patients had ever been
Referred to Home Care Tele-health was not available at the Hospital-based
Home Health Agency
HOSPITAL READMISSION STUDYWITHIN THE 30-DAY DRG PERIOD
External Review of Readmission DRGs 231 Readmitted Patients (34%) should have been
in Home Care Only 34 of the Readmitted patient were referred to
home care Potential Savings to Hospital of 2,752 days
(33.50%) @ $1,835 = $5,049,900 Additional Revenue to Home Care Agency =
$482,650 Estimated 197 Episodes @ $2,450
HOSPITAL READMISSION STUDYWITHIN THE 30-DAY DRG PERIOD
External Review of Readmission DRGs 449 Readmitted Patients (66%) should not have been
referred to Home Care Could have been eligible for a “Transitions in Care”
program Potential savings of a significant portion of the
$10,022,800 in vacated days cost!
Pat Laff, Managing Partner, Laff Associates
Walt Borginis, Executive Vice President/CFO, VNA of Philadelphia
Barbara Rosenblum, Founder and CEO of Strategic Healthcare Programs (SHP)
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